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Psychiatry (mixed 2) > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

Characteristics of typical (1st gen) antipsychotics?

A
  • High affinity for D2 receptors
  • Alleviate positive symptoms of schizophrenia, mostly
  • Can block multiple dopamine pathways in the brain –> greater chance of EPSE’s
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2
Q

Characteristics of atypical (2nd gen) antipsychotics?

A
  • Lower affinity for D2 receptors
  • Bind preferentially to serotonin and histamine receptors
  • Greater ACh effect –> less EPSE’s
  • Generally more metabolic S/E e.g. weight gain
  • Greater effect on negative symptoms than 1st gen
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3
Q

What are the EPSEs?

A
  1. Acute dystonia
  2. Akathisia
  3. Parkinsonism
  4. Tardive dyskinesia
  5. Neuroleptic malignant syndrome (rare, but NB)
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4
Q

What is acute dystonia?

A

Continuous, sustained or repetitive spasms and muscle contractions resulting in twisting and repetitive movements and abnormal fixed postures
More common in young males

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5
Q

What is akathisia?

A

A feeling of internal motor restlessness and the compelling need to be in constant motion

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6
Q

What is Parkinsonism?

A

Symptoms of Parkinson’s Disease due to neuroleptics inhibiting substantia nigra, which regulates the extrapyramidal system

  • Tremor
  • Bradykinesia
  • Rigidity
  • Postural instability
  • Shuffling gait
  • Mask-like face
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7
Q

What is tardive dyskinesia?

A

Involuntary, repetitive muscle movements in the lower face and distal extremities. Includes grimacing, sticking out the tongue, lip smacking and puckering, and excessive blinking. Movements can be slow and writhing or rapid and jerking
More common in females

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8
Q

What is neuroleptic malignant syndrome?

A

A life-threatening reaction to neuroleptics, characterised by:

  • Clinical features:
  • High fever, sweating, tachycardia
  • Rigidity
  • Confusion
  • Autonomic instability
  • Laboratory features:
  • Creatine kinase (in the thousands)
  • Leucocytosis
  • Raised transaminases
  • Hyperkalaemia
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9
Q

What is lithium?

A

A mineral salt, which acts as a mood stabiliser with both antimanic and antidepressant effects

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10
Q

Indications for lithium?

A
  • Treatment of acute mania
  • Prophylaxis of bipolar disorders
  • Patients with aggressive or self-mutilating behaviour
  • Treatment-resistant/recurrent unipolar depression
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11
Q

Contraindications for lithium?

A
  • CNS disorders e.g. epilepsy
  • Cardiac disease
  • Renal impairment or urinary retention
  • Pregnancy category D
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12
Q

Cautionary groups for lithium?

A
  • Concomitant use with medications or conditions that interfere with water and electrolyte balance
  • Geriatrics: lower doses, lower target levels, frequent monitoring
  • Paediatrics: not recommended in <12 y/o
  • Pregnancy category D, but in some cases may be used
  • Lactation: excreted in breastmilk at high concentrations
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13
Q

Drug interactions for lithium?

A
  • Neuroleptics: may aggravate EPSEs
  • SSRIs: increased risk of serotonin syndrome, may elevate serum [lithium]
  • Xanthines e.g. caffeine, theophylline: increased renal excretion of lithium
  • Antithyroid agents or iodides
  • ACEI and ARBs
  • NSAIDs: increased risk of toxicity
  • Thiazide and loop diuretics: lithium excretion delayed –> increased serum levels with increased risk of toxicity
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14
Q

Adverse effects of lithium?

A
  • Dose-related toxic effects: ataxia, lethargy, weakness, confusion, tremor, convulsions, hyperreflexia
  • Common:
  • Blurred vision
  • Metal taste, thirsty, polyuria, polydipsia (usually mild, early in therapy, settles spontaneously)
  • Fine tremor
  • GIT disturbances (N/V/D)
  • Weight gain
  • Renal:
  • Acute increase in creatinine –> STOP if increased creatinine and protein in urine
  • Oedema (may disappear spontaneously after several days)
  • Rare:
  • EPSE’s, even at therapeutic levels
  • Hypothyroidism
  • Nephrogenic diabetes insipidus
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15
Q

Dosing of lithium?

A

10-20mg/kg/day initially, divided twice daily for first week, then give OD to decrease renal S/E
Adjust to reach therapeutic, non-toxic concentrations

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16
Q

What are the normal ranges for lithium serum concentration? When is this measured?

A

Bipolar: aim for 0.6 -1.2 mmol/l
Augmentation of antidepressant: aim for 0.4-0.8 mmol/l
Measure lithium trough levels 12 hours after last dose i.e. directly before next dose
Toxicity if levels > 1.5 mmol/l

17
Q

How frequently are lithium levels measured?

A
  • One week after each dose increment, thereafter:
  • At one month
  • At three months
  • 6 monthly during maintenance
18
Q

Therapeutic drug monitoring for lithium?

A
  • TSH, calcium and renal function (GFR, creatinine) before initiation
  • Thereafter check thyroid and renal functions 6-12 monthly
19
Q

Teratogenic effects of lithium?

A
  • Pregnancy category D
  • Increased incidence of cardiovascular (in particular Ebstein’s anomaly - atrialisation of right ventricle due to displacement of tricuspid valve leaflets - although the incidence has been overstated) anomalies
  • Changes in lithium therapeutic levels during pregnancy and around birth - NB potential for toxicity for mum after birth
  • Neonatal complications:
  • Goitre
  • Arrhythmias and CCF
  • Floppy infant syndrome (hypotonia, poor respiration, cyanosis)
20
Q

Cutoffs for lithium toxicity?

A

*Therapeutic levels:
- Generally: 0.6 - 1.2 mmol/l
- Geriatrics: 0.4 - 0.7 mmol/l
*Toxicity:
- Mild: 1.5 - 2.5
- Moderate 2.5 - 3.5
- Severe: >3.5
Poor correlation between [lithium] and severity of symptoms

21
Q

Clinical features of lithium toxicity?

A 
Neurological:
- Altered mental state - delirium - convulsions - comatose
- Apathy, restlessness
- Ataxia
- Dysarthria
- Tremor, fasciculation
Other:
- Renal dysfunction - electrolyte disturbances
- Nausea/vomiting/diarrhoea
22
Q

Management of lithium toxicity?

A
  • Activated charcoal NOT effective
  • Gastric lavage only indicated if 1-2 hours after substantial acute overdose
  • Closely monitor: hydration, electrolytes (K), lithium levels
  • Administer 2-3l/day of 0.9% NaCl, IF NOT in renal or cardiac failure
  • Treatment of choice = haemodialysis (repeats may be needed due to rebound of serum levels due to redistribution, ongoing GIT absorption)
23
Q

What is the mechanism of action of lithium?

A

Unknown, but believed to act centrally to decrease norepinephrine and increase serotonin

Psychiatry (mixed 2) (16 decks)

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